4 T'he Li'er Cancer Study Group ot'Japan. Primary liver cancer in Japan. Ann Surg 1990;211:277-87. S Nagorney DM, van Heerden JA, Ilstrup DM, Adson MA. Primary hepatic malignancy: surgical management attd determinants of survival. Surgery 1989;106:740-9. 6 'Tang ZY, Yu YQ, Zhou XD, Ma ZC, Yang R, Lu JZ, et al. Surgery of' small hepatocellular carcinoma: analysis of 144 cases. Cancer 1989;64:536-41. 7 Zhou XD, TFang Y, Yu YQ, Ma ZC, Yang R, Lu JZ, et al. Solitarv minute hepato ellular carcinoma: a study ot 14 patients. Cancer 1991;67:2855-8. 8 Nagasue N, Yukaya H, Ogawa Y, Sasaki Y, Chang YC, Niimi K. Clinical experience with 118 hepatic resections t'or hepatocellular carcinoma. Surgersy 1986;99:694-70 1. 9 Ebara MN1, Ohto M, Shinagawa T, Sugiura N, Kimura K, Matsutani S, ct al. Natural history of minute hepatocellular carcinoma smaller than three centimeters complicating cirrhosis.
Gastroenterology 1986;90:289-98. 10 Nagasue N, Yukaya H, Chang YC, Ogawa Y, Ota N, Kimura N, et al. Appraisal of hepatic resection in the treatment of minute hepatocellular carcinoma associated with liver cirrhosis. Br]
Surg 1987;74:836-8. 11
12 13 14
15
Franco D. Morphological and histological features of resected hepatocellular carcinoma in cirrhotic patients in the west. Hepatology 1989;9:253-7. Makuuchi M, Mori T, Guns-en P, Yamazaki S, Hasegawa H. Safety of hemihepatic vascular occlusion during rcsection of the liver. Surg Gvnecol Obstet 1987;164:155-8. Registry of Hepatic M\etastases. Resection of the liver for colorectal carcinoma metastases: a multiinstitutional study of indications for resection. Surgery 1988;103:278-87. Ezaki T, Yukaya H, Ogawa Y. Evaluation of hepatic resection for hepatocellular carcinoma in the elderly. Brj Surg 1987;74:471-3. Lin TY, Lee CS, Chen KM, Chen CC. Role of surgerv in the treatment of primarv carcinoma of the liver: a 31 sear experience. Brj Surg 1987;74:839-42.
Kemeny F, Vadrot J, Wu A, Smadja C, Meakins JL,
16 Kanematsu T, Matsumata r, 'Fakenaka K, Yoshia Y, Higashi H, Sugimachi K. Clinical management of recurrent hepatocellular carcinoma after primary rcsection. Br J Surg 1988;75:203-6. 17 Nagao T, Inoue S, Yoshimi F, Sodeyama M, Omori Y, Mizuta 'l', et al. Postoperative recurrence of hepatocellular carcinoma. Ann Surg 1990;211:28-33. 18 Yamada R, Sato M, Kawabata M, Nakatsuka H, Nakamura K, Takashima S. Hepatic artery emboli7ation in 120 patients with unresectable hepatoma. Radiology 1983;148:397-401. 19 Kanematsu T, Furuta T, Takenaka K, MIatsumata T, Yoshida Y, Nishizaki T, et al. A 5-year experience of lipiodolization: selective regional chemotherapy for 200 patients with hepatocellular carcinoma. Hepatology 1989;10:98-102. 20 Shiina 5, Yasuda H, Muto H, Tagawa K, Unuma T, Ibukuro K, et al. Percutaneous ethanol injection in the treatment of liver neoplasms. AJ7R 1987;149:949-52. 21 Livraghi T, Salmi A, Bolondi L, Marin G, Arienti V? Monti F, et al. Small hepatocellular carcinoma: percutaneous alcohol injection. Results in 23 patients. Radiology 1988;168:313-7. 22 'Takayasu K, Muramatsu Y, Moriyama N, Hasegawa H, Makuuchi M, Okazaki N, et al. Clinical and radiologic assessments of the results of hepatectomy for small hepatocellular carcinoma and therapeutic arterial embolization for postoperative recurrence. Cancer 1989;64:1848-52. 23 'ranikawa K. Non-surgical treatment of hepatocellular carcinoma. Jpn J Gastroenterol Surg 1990;23:2492-6. (Japanese with English abstract.) 24 Iwatasuki S, Gordon RD, Show BW Jr, Starzl TE. Role of liver transplantation in cancer therapy. Ann Surg 1985;202:401-7. 25 O'Grady JG, Polson RJ, Calne RY, Williams R. Liver transplantation for malignant disease: results in 93 consecutive patients. Ann Surg 1988;207:303-9. 26 Ringe B, Wittekind C, Bechstein WO, Bunzendahl H, Pichlmayr R. The role of liver transplantation in hepatobiliary malignancy. A retrospective analysis of 95 patients with particular regard to tumor stage and recurrence. Ann Surg 1989;209:88-98.
Ocular injuries from boxing What about prophylactic laser coagulation of boxers' retinas? All sports have their popular heroes, and the sound of leather on Gooch's willow or the crack of Faldo's drive are evocative of their powerful prowess. Indeed, the wheezy thud of a boxer's cushioned fist may betoken a force of over half a tonne, as in the instance of Frank Bruno's fiercest punch.' Anxieties over the dangers of boxing were never more publicly debated than when Britain's best loved sportsman was himself found to have sustained serious ocular trauma. The eyes and adnexae of boxers suffer a panoply of blunt injuries, from orbital blow out fracture to "cauliflower choroid."2 Apart from periorbital swelling and laceration, most damage arises from diffuse impact on the eyeball from the knuckle or thumb of the glove. Fair blow or foul, the effect of such frontal assault is a momentary deformation of the globe3 similar to that of a golf ball on impact. Because of the differential elasticity between the outer wall and contents of the eye, disruption of intraocular tissue ensues, especially at the iris root in the anterior chamber drainage angle, within the lens, or through the attachments of the vitreous to the retina. Few of the injuries give rise to symptoms or immediate visual loss, but in a sample of active professional boxers, 58% had at least one sight threatening injury to the angle, lens, or retina (half had bilateral damage).4 Ripping of the retina at its anterior annular limit (the ora serrata), often with avulsion of a strip of oral tissue, is pathognomonic of blunt trauma and has been reproduced by firing bullets at the cornea of excised pig eyes.3 The retinal breaks thus differ from those causing spontaneous retinal detachment in old age or myopia. The breaks may extend over 90 degrees of the retinal circumference-"giant tears"-as have occurred recently in three senior British heavyweights (one sustained bilateral giant tears). The subsequent traumatic retinal detachments are often slow to progress towards the
towards injury but is difficult to quantitate4 while the importance of myopia (whether by virtue of increased scleral elasticity, relative proptosis, or susceptibility to retinal tearing) is unproved. Racial factors may be relevant; black people are apt to have a shallow orbit but have a reduced tendency to retinal detachment.5 Another factor may be the orbital swelling that often develops during a hard fight. Banning boxing, regarded by some as a mark of a civilised society6 but by others as "a modest tyranny,"7 would obviously provide the ultimate prophylaxis. (Ophthalmologists dealing with boxing injuries do well to distance themselves from the moral dilemma, not least because their management objective-cure and rehabilitation of their patient-may necessitate advising the boxing authorities on whether resumption of boxing should be permitted; the sport's limited credibility and sometimes millions of pounds in purse money ride on these decisions.) Revision of the official target area to exclude the head and the use of thumbless boxing gloves"8 are resisted by punter and pugilist, but the British Boxing Board of Control has a visual standard, one purpose of which is to exclude boxers with appreciable myopia. A new strategy might be to undertake laser coagulation of boxers' peripheral retina, which, although unlikely to prevent retinal tearing, should limit retinal detachment. But the effectiveness of any preventive measures (whether thumbless gloves or retinal laser coagulation) could be judged only by a sorely needed longitudinal survey. Does the boxing board have the courage and clout to stage such a study?
after macula and may present some months or even years the
1 Atha J, Yeadon MR, Sandover J, Parsons KC. The damaging punch. BMJf 1985;291: 1756-7. 2 Doggart JH. Fisticuffs and the sisual organs. Transactionsofthe Ophthalmological Societyof the UK 3 Weidenthal DT, Schepens CL. Peripheral fundus changes associated with ocular contusion. Am]X 4 GoiazV,nuzLASorensonJA, Delrowe DJ, Cambell LA. The ocular complieattons of boxing. Ophthalmology 1987;94:587-96.
injury. Nevertheless, with modern retinal and vitreoretinal on) surgical techniques, including (but not wholly dependent the use of lasers, the damage can generally be successfully
repaired and the retina even deemed more secure than before e lnlury.
DAVID McLEOD
Professor of Ophthalmology,
Manchester Royal Eye Hospital, Manchester Ml 3 9WH
s~~~~~~~~~~~~~~~~~~~~~~~~ Foos RY, Simons KB, Wheeler NC. Comparison of lesions predisposing of rhegmatogenous retinal by race of subjects. A.4w Ophtthalmol 1983;96:644-9. ~~~~~~~~~~~~~~~~~~~~~~detachment
1986;255:2483-5. 3.]AMA 6 Lundberg GD. Boxing should be banned in civilised countries-round itS the globe and The anthropometric relation between 1986;255:2481-2. AMA * ~~~~~~~~7 Patterson RH. Commnentary: On boxing and liberty!.J.................... ,-
prOteCtlVe OrtZlalSnell 1S Clerly lMpOrtant l
BMJ
VOLUME 304
25 JANUARY 1992
**
preAlSpOSlNg
8Smith DJ.Ocular injuries in boxing. Ins fphthalmol Clin 1988;28:242-5. 197
Gastroenterology 1986;90:289-98. 10 Nagasue N, Yukaya H, Chang YC, Ogawa Y, Ota N, Kimura N, et al. Appraisal of hepatic resection in the treatment of minute hepatocellular carcinoma associated with liver cirrhosis. Br]
Surg 1987;74:836-8. 11
12 13 14
15
Franco D. Morphological and histological features of resected hepatocellular carcinoma in cirrhotic patients in the west. Hepatology 1989;9:253-7. Makuuchi M, Mori T, Guns-en P, Yamazaki S, Hasegawa H. Safety of hemihepatic vascular occlusion during rcsection of the liver. Surg Gvnecol Obstet 1987;164:155-8. Registry of Hepatic M\etastases. Resection of the liver for colorectal carcinoma metastases: a multiinstitutional study of indications for resection. Surgery 1988;103:278-87. Ezaki T, Yukaya H, Ogawa Y. Evaluation of hepatic resection for hepatocellular carcinoma in the elderly. Brj Surg 1987;74:471-3. Lin TY, Lee CS, Chen KM, Chen CC. Role of surgerv in the treatment of primarv carcinoma of the liver: a 31 sear experience. Brj Surg 1987;74:839-42.
Kemeny F, Vadrot J, Wu A, Smadja C, Meakins JL,
16 Kanematsu T, Matsumata r, 'Fakenaka K, Yoshia Y, Higashi H, Sugimachi K. Clinical management of recurrent hepatocellular carcinoma after primary rcsection. Br J Surg 1988;75:203-6. 17 Nagao T, Inoue S, Yoshimi F, Sodeyama M, Omori Y, Mizuta 'l', et al. Postoperative recurrence of hepatocellular carcinoma. Ann Surg 1990;211:28-33. 18 Yamada R, Sato M, Kawabata M, Nakatsuka H, Nakamura K, Takashima S. Hepatic artery emboli7ation in 120 patients with unresectable hepatoma. Radiology 1983;148:397-401. 19 Kanematsu T, Furuta T, Takenaka K, MIatsumata T, Yoshida Y, Nishizaki T, et al. A 5-year experience of lipiodolization: selective regional chemotherapy for 200 patients with hepatocellular carcinoma. Hepatology 1989;10:98-102. 20 Shiina 5, Yasuda H, Muto H, Tagawa K, Unuma T, Ibukuro K, et al. Percutaneous ethanol injection in the treatment of liver neoplasms. AJ7R 1987;149:949-52. 21 Livraghi T, Salmi A, Bolondi L, Marin G, Arienti V? Monti F, et al. Small hepatocellular carcinoma: percutaneous alcohol injection. Results in 23 patients. Radiology 1988;168:313-7. 22 'Takayasu K, Muramatsu Y, Moriyama N, Hasegawa H, Makuuchi M, Okazaki N, et al. Clinical and radiologic assessments of the results of hepatectomy for small hepatocellular carcinoma and therapeutic arterial embolization for postoperative recurrence. Cancer 1989;64:1848-52. 23 'ranikawa K. Non-surgical treatment of hepatocellular carcinoma. Jpn J Gastroenterol Surg 1990;23:2492-6. (Japanese with English abstract.) 24 Iwatasuki S, Gordon RD, Show BW Jr, Starzl TE. Role of liver transplantation in cancer therapy. Ann Surg 1985;202:401-7. 25 O'Grady JG, Polson RJ, Calne RY, Williams R. Liver transplantation for malignant disease: results in 93 consecutive patients. Ann Surg 1988;207:303-9. 26 Ringe B, Wittekind C, Bechstein WO, Bunzendahl H, Pichlmayr R. The role of liver transplantation in hepatobiliary malignancy. A retrospective analysis of 95 patients with particular regard to tumor stage and recurrence. Ann Surg 1989;209:88-98.
Ocular injuries from boxing What about prophylactic laser coagulation of boxers' retinas? All sports have their popular heroes, and the sound of leather on Gooch's willow or the crack of Faldo's drive are evocative of their powerful prowess. Indeed, the wheezy thud of a boxer's cushioned fist may betoken a force of over half a tonne, as in the instance of Frank Bruno's fiercest punch.' Anxieties over the dangers of boxing were never more publicly debated than when Britain's best loved sportsman was himself found to have sustained serious ocular trauma. The eyes and adnexae of boxers suffer a panoply of blunt injuries, from orbital blow out fracture to "cauliflower choroid."2 Apart from periorbital swelling and laceration, most damage arises from diffuse impact on the eyeball from the knuckle or thumb of the glove. Fair blow or foul, the effect of such frontal assault is a momentary deformation of the globe3 similar to that of a golf ball on impact. Because of the differential elasticity between the outer wall and contents of the eye, disruption of intraocular tissue ensues, especially at the iris root in the anterior chamber drainage angle, within the lens, or through the attachments of the vitreous to the retina. Few of the injuries give rise to symptoms or immediate visual loss, but in a sample of active professional boxers, 58% had at least one sight threatening injury to the angle, lens, or retina (half had bilateral damage).4 Ripping of the retina at its anterior annular limit (the ora serrata), often with avulsion of a strip of oral tissue, is pathognomonic of blunt trauma and has been reproduced by firing bullets at the cornea of excised pig eyes.3 The retinal breaks thus differ from those causing spontaneous retinal detachment in old age or myopia. The breaks may extend over 90 degrees of the retinal circumference-"giant tears"-as have occurred recently in three senior British heavyweights (one sustained bilateral giant tears). The subsequent traumatic retinal detachments are often slow to progress towards the
towards injury but is difficult to quantitate4 while the importance of myopia (whether by virtue of increased scleral elasticity, relative proptosis, or susceptibility to retinal tearing) is unproved. Racial factors may be relevant; black people are apt to have a shallow orbit but have a reduced tendency to retinal detachment.5 Another factor may be the orbital swelling that often develops during a hard fight. Banning boxing, regarded by some as a mark of a civilised society6 but by others as "a modest tyranny,"7 would obviously provide the ultimate prophylaxis. (Ophthalmologists dealing with boxing injuries do well to distance themselves from the moral dilemma, not least because their management objective-cure and rehabilitation of their patient-may necessitate advising the boxing authorities on whether resumption of boxing should be permitted; the sport's limited credibility and sometimes millions of pounds in purse money ride on these decisions.) Revision of the official target area to exclude the head and the use of thumbless boxing gloves"8 are resisted by punter and pugilist, but the British Boxing Board of Control has a visual standard, one purpose of which is to exclude boxers with appreciable myopia. A new strategy might be to undertake laser coagulation of boxers' peripheral retina, which, although unlikely to prevent retinal tearing, should limit retinal detachment. But the effectiveness of any preventive measures (whether thumbless gloves or retinal laser coagulation) could be judged only by a sorely needed longitudinal survey. Does the boxing board have the courage and clout to stage such a study?
after macula and may present some months or even years the
1 Atha J, Yeadon MR, Sandover J, Parsons KC. The damaging punch. BMJf 1985;291: 1756-7. 2 Doggart JH. Fisticuffs and the sisual organs. Transactionsofthe Ophthalmological Societyof the UK 3 Weidenthal DT, Schepens CL. Peripheral fundus changes associated with ocular contusion. Am]X 4 GoiazV,nuzLASorensonJA, Delrowe DJ, Cambell LA. The ocular complieattons of boxing. Ophthalmology 1987;94:587-96.
injury. Nevertheless, with modern retinal and vitreoretinal on) surgical techniques, including (but not wholly dependent the use of lasers, the damage can generally be successfully
repaired and the retina even deemed more secure than before e lnlury.
DAVID McLEOD
Professor of Ophthalmology,
Manchester Royal Eye Hospital, Manchester Ml 3 9WH
s~~~~~~~~~~~~~~~~~~~~~~~~ Foos RY, Simons KB, Wheeler NC. Comparison of lesions predisposing of rhegmatogenous retinal by race of subjects. A.4w Ophtthalmol 1983;96:644-9. ~~~~~~~~~~~~~~~~~~~~~~detachment
1986;255:2483-5. 3.]AMA 6 Lundberg GD. Boxing should be banned in civilised countries-round itS the globe and The anthropometric relation between 1986;255:2481-2. AMA * ~~~~~~~~7 Patterson RH. Commnentary: On boxing and liberty!.J.................... ,-
prOteCtlVe OrtZlalSnell 1S Clerly lMpOrtant l
BMJ
VOLUME 304
25 JANUARY 1992
**
preAlSpOSlNg
8Smith DJ.Ocular injuries in boxing. Ins fphthalmol Clin 1988;28:242-5. 197
